CH RAD-Order (R4)
2.0.0 - trial-use Switzerland flag

CH RAD-Order (R4), published by HL7 Switzerland. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7ch/ch-rad-order/ and changes regularly. See the Directory of published versions

Example QuestionnaireResponse: QuestionniaireResponse Radiology Order for second Opinion

Generated Narrative: QuestionnaireResponse QuestionnaireResponseRadiologyOrderSecondOpinion

LinkIDTextDefinitionAnswerdoco
.. QuestionnaireResponseRadiologyOrderSecondOpinionQuestionnaire:QuestionnaireRadiologyOrder
... orderAuftrag
.... order.authoredOnDatum/Zeit der Auftragserteilung2024-11-17T11:28:17+01:00
.... order.placerOrderIdentifierAuftragsnummer des Auftraggebers123
.... order.placerOrderIdentifierDomainIdentifier Domain der Auftragsnummer des Auftraggebersurn:oid:2.999.1.3.4.5.6.7
.... order.fillerOrderIdentifierAuftragsnummer des Auftragsempfängers456
.... order.fillerOrderIdentifierDomainIdentifier Domain der Auftragsnummer des Auftragsempfängersurn:oid:2.999.7.8.9.10.11
.... order.precedentDocumentIdentifierIdentifier des Vorgängerdokuments
.... order.notificationContactDocumentDringender Benachrichtigungskontakt für dieses Dokument
..... order.notificationContactDocument.practitionerZu benachrichtigende Person
...... order.notificationContactDocument.practitioner.titleTitel
...... order.notificationContactDocument.practitioner.familyNameName
...... order.notificationContactDocument.practitioner.givenNameVorname
...... order.notificationContactDocument.practitioner.phoneTelefon
...... order.notificationContactDocument.practitioner.emailE-Mail
.... order.notificationContactDocumentResponseDringender Benachrichtigungskontakt für die Antwort auf dieses Dokument
..... order.notificationContactDocumentResponse.practitionerZu benachrichtigende Person
...... order.notificationContactDocumentResponse.practitioner.titleTitelDr. med.
...... order.notificationContactDocumentResponse.practitioner.familyNameNameRderplacer
...... order.notificationContactDocumentResponse.practitioner.givenNameVornameOttilie
...... order.notificationContactDocumentResponse.practitioner.phoneTelefon044 333 22 11
...... order.notificationContactDocumentResponse.practitioner.emailE-Mailottilie.rderplacer@happydoctors.ch
.... order.priorityAuftragsprioritätRequestPriority routine: Routine
... receiverEmpfänger
.... receiver.practitionerEmpfangende Person
..... receiver.practitioner.titleTitelDr. med.
..... receiver.practitioner.familyNameNameRderfiller
..... receiver.practitioner.givenNameVornameOtto
..... receiver.practitioner.glnGLN7601000087232
..... receiver.practitioner.zsrZSRA123262
..... receiver.practitioner.phoneTelefon044 412 00 99
..... receiver.practitioner.emailE-Mailotto.rderfiller@happyhospital.ch
.... receiver.organizationEmpfangende Organisation
..... receiver.organization.nameName der OrganisationRadiologie Klinik Happyhospital
..... receiver.organization.streetAddressLineStrasse, Hausnummer, Postfach etc.Kantonsstrasse 133
..... receiver.organization.postalCodePLZ8000
..... receiver.organization.cityOrtZürich
..... receiver.organization.countryLandSchweiz
... initiatorInitiant dieser Anmeldung
.... initiator.legalrelationJuristische Beziehung zum Patienten
.... initiator.personalrelationPersönliche Beziehung zum Patienten?
.... initiator.practitionerRoleGesundheitsfachperson oder -organisation
..... initiator.practitionerRole.practitionerGesundheitsfachperson
...... initiator.practitionerRole.practitioner.titleTitel
...... initiator.practitionerRole.practitioner.familyNameName
...... initiator.practitionerRole.practitioner.givenNameVorname
...... initiator.practitionerRole.practitioner.phoneTelefon
...... initiator.practitionerRole.practitioner.emailE-Mail
..... initiator.practitionerRole.organizationGesundheitsorganisatiton
...... initiator.practitionerRole.organization.nameName der Organisation
...... initiator.practitionerRole.organization.streetAddressLineStrasse, Hausnummer, Postfach etc.
...... initiator.practitionerRole.organization.postalCodePLZ
...... initiator.practitionerRole.organization.cityOrt
...... initiator.practitionerRole.organization.countryLand
.... initiator.relatedPerson
..... initiator.relatedPerson.familyNameName
..... initiator.relatedPerson.givenNameVorname
... patientPatient
.... patient.familyNameNameUfferer
.... patient.maidenNameLedignameLeidend
.... patient.givenNameVornameSusanna
.... patient.localPidLokale Patienten-ID11.22.33.4567
.... patient.localPidDomainLokale Patienten-ID Domainurn:oid:2.999.1.2.3.4
.... patient.birthDateGeburtsdatum1945-03-14
.... patient.genderGeschlechtAdministrativeGender female: Female
.... patient.maritalStatusZivilstandeCH-011 MaritalStatus 3: verwitwet
.... patient.phoneTelefon079 979 79 79
.... patient.emailE-Mailsusanna@ufferer.ch
.... patient.streetAddressLineStrasse, Hausnummer, Postfach etc.Musterweg 6a
.... patient.postalCodePLZ8000
.... patient.cityOrtZürich
.... patient.countryLandSchweiz
.... patient.languageOfCorrespondenceKorrespondenzspracheTags for the Identification of Languages de-CH: German (Switzerland)
.... patient.contactpersonKontaktperson
..... patient.contactperson.relationshipBeziehungGuter Freund
..... patient.contactperson.familyNameNameFreund
..... patient.contactperson.givenNameVornameMax
..... patient.contactperson.phoneTelefon079 111 22 33
..... patient.contactperson.emailE-Mailmax@freund.ch
.... familydoctorHausarzt
..... familydoctor.practitionerHausarzt Person
...... familydoctor.practitioner.titleTitelDr. med.
...... familydoctor.practitioner.familyNameNameRderplacer
...... familydoctor.practitioner.givenNameVornameOttilie
...... familydoctor.practitioner.glnGLN
...... familydoctor.practitioner.zsrZSR
...... familydoctor.practitioner.phoneTelefon
...... familydoctor.practitioner.emailE-Mail
..... familydoctor.organizationHausarzt Organisation
...... familydoctor.organization.nameName der Organisation
...... familydoctor.organization.countryLand
... requestedEncounterPatientenaufnahme
.... requestedEncounter.classVoraussichtlich: Ambulant / Stationär / Notfall
.... requestedEncounter.desiredAccommodationZimmerkategorie
... coverageKostenträger
.... coverage.kvgKrankenkasse (nach KVG)
..... coverage.kvg.nameName der VersicherungOrgSanitas
..... coverage.kvg.insuranceCardNumberKennnummer der Versichertenkarte80756015090002647590
... senderAbsender
.... sender.authorVerantwortlicher
..... sender.author.practitionerVerantwortliche Person
...... sender.author.practitioner.titleTitelDr. med.
...... sender.author.practitioner.familyNameNameRderplacer
...... sender.author.practitioner.givenNameVornameOttilie
...... sender.author.practitioner.glnGLN7601000618627
...... sender.author.practitioner.zsrZSRA123321
...... sender.author.practitioner.phoneTelefon044 333 22 11
...... sender.author.practitioner.emailE-Mailottilie.rderplacer@happydoctors.ch
..... sender.author.organizationVerantwortliche Organisation
...... sender.author.organization.nameName der OrganisationGemeinschaftspraxis Happydoctors
...... sender.author.organization.streetAddressLineStrasse, Hausnummer, Postfach etc.Happystrasse 14
...... sender.author.organization.postalCodePLZ8000
...... sender.author.organization.cityOrtZürich
...... sender.author.organization.countryLandSchweiz
.... sender.dataentererErfasser
..... sender.dataenterer.practitionerErfassende Person
...... sender.dataenterer.practitioner.familyNameNameAtaenterer
...... sender.dataenterer.practitioner.givenNameVornameDoris
...... sender.dataenterer.practitioner.phoneTelefon044 333 22 12
...... sender.dataenterer.practitioner.emailE-Maild.ataenterer@happydoctors.ch
... receiverCopyKopieempfänger (Kopie dieses Auftrags und aller daraus resultierenden Resultate)
.... receiverCopy.practitionerRoleGesundheitsfachperson oder -organisation
..... receiverCopy.practitionerRole.practitionerGesundheitsfachperson
...... receiverCopy.practitionerRole.practitioner.titleTitel
...... receiverCopy.practitionerRole.practitioner.familyNameName
...... receiverCopy.practitionerRole.practitioner.givenNameVorname
...... receiverCopy.practitionerRole.practitioner.phoneTelefon
...... receiverCopy.practitionerRole.practitioner.emailE-Mail
..... receiverCopy.practitionerRole.organization
...... receiverCopy.practitionerRole.organization.nameName der Organisation
...... receiverCopy.practitionerRole.organization.streetAddressLineStrasse, Hausnummer, Postfach etc.
...... receiverCopy.practitionerRole.organization.postalCodePLZ
...... receiverCopy.practitionerRole.organization.cityOrt
...... receiverCopy.practitionerRole.organization.countryLand
.... receiverCopy.patientPatient selbstfalse
... antecedentEpisodeOfCareVorgängiger Aufenthalt in Spital / Heim
.... antecedentEpisodeOfCare.startVon
.... antecedentEpisodeOfCare.endBis
.... antecedentEpisodeOfCare.organizationSpital /Heim
..... antecedentEpisodeOfCare.organization.nameName der Organisation
..... antecedentEpisodeOfCare.organization.streetAddressLineStrasse, Hausnummer, Postfach etc.
..... antecedentEpisodeOfCare.organization.postalCodePLZ
..... antecedentEpisodeOfCare.organization.cityOrt
..... antecedentEpisodeOfCare.organization.countryLand
... consentEinverständniserklärung
.... patient.consent.statementIst der Patient über die Anmeldung informiert und explizit einverstanden?Consent Status ExplicitAgreement: Patient is informed and has explicitly agreed
..... patient.consent.statement.noteAnmerkung
... medicalInformation
.... requestedServiceAngeforderte Leistung
..... requestedService.serviceLeistungRequested Service SecondOpinion: Zweitmeinung
.... reasonKlinische Fragestellung
..... reason.questionFragestellungIst die Fraktur stabil? Verzicht auf Chir. Vorgehen?
.... imagingServiceBildgebendes Verfahren
..... imagingService.typeArtRadLex radiology lexicon RID10321: Computed Tomography
.... orderDetailWeitere Angaben zur Bildgebung
..... orderDetail.imagingRegionRegionRadLex radiology lexicon RID2638: Lower extremity
..... orderDetail.imagingFocusFokusRadLex radiology lexicon RID2639: Hip
..... orderDetail.lateralitySeitenangabeRadLex radiology lexicon RID5824: left
..... orderDetail.viewTypeAnsicht
..... orderDetail.maneuverTypeManöver
..... orderDetail.guidanceForActionHandlungsanleitung
.... desiredRadiologistGewünschter Radiologe für die Befundung / für die Intervention
..... desiredRadiologist.familyNameNameRderfiller
..... desiredRadiologist.givenNameVornameOtto
... diagnosis
.... diagnosisListDiagnosen und Befunde
..... diagnosisList.primaryDiagnosisHauptdiagnoseVerdacht auf Pneumonie
..... diagnosisList.secondaryDiagnosisNebendiagnose
..... diagnosisList.bodyHeightGrösse (cm)176 cm (Details: UCUM codecm = 'cm')
..... diagnosisList.bodyWeightGewicht (kg)99 kg (Details: UCUM codekg = 'kg')
... caveats
.... caveatListCaveats
..... caveatList.bloodCoagulationBeinträchtigte BlutgerinnungSNOMED CT 52101004: Present
...... caveatList.bloodCoagulation.INRINR
....... caveatList.bloodCoagulation.INR.quantityWert (INR)2.7
....... caveatList.bloodCoagulation.INR.dateTimeZeitpunkt der Bestimmung2024-02-01T10:10:00.000+00:00
...... caveatList.bloodCoagulation.plateletsThrombozyten
....... caveatList.bloodCoagulation.platelets.quantityWert (10^9/L)200 10^9/L (Details: UCUM code10^9/L = '10^9/L')
....... caveatList.bloodCoagulation.platelets.dateTimeZeitpunkt der Bestimmung2024-02-01T10:10:00.000+00:00
..... caveatList.renalInsufficiencyNiereninsuffizienzSNOMED CT 52101004: Present
...... caveatList.renalInsufficiency.creatinineClearanceCreatinin-Clearance
....... caveatList.renalInsufficiency.creatinineClearance.quantityWert (mL/min)55 mL/min (Details: UCUM codemL/min = 'mL/min')
....... caveatList.renalInsufficiency.creatinineClearance.dateTimeZeitpunkt der Bestimmung2024-02-01T10:10:00.000+00:00
...... caveatList.renalInsufficiency.creatinineCreatinin
....... caveatList.renalInsufficiency.creatinine.quantityWert (µmol/L)90 umol/L (Details: UCUM codeumol/L = 'umol/L')
....... caveatList.renalInsufficiency.creatinine.dateTimeZeitpunkt der Bestimmung2024-02-01T10:10:00.000+00:00
..... caveatList.claustrophobiaKlaustrophobieSNOMED CT 373068000: Undetermined (qualifier value)
..... caveatList.bodyPiercingKörperpiercingSNOMED CT 373068000: Undetermined (qualifier value)
..... caveatList.deviceDevice (Herzschrittmacher, Herzklappenersatz, Insulinpumpe etc.)SNOMED CT 441509002: Cardiac pacemaker in situ
..... caveatList.hyperthyroidismHyperthyreoseSNOMED CT 373068000: Undetermined (qualifier value)
..... caveatList.diabetesDiabetes mellitusSNOMED CT 373068000: Undetermined (qualifier value)
..... caveatList.gravidaSchwangerschaftSNOMED CT 373068000: Undetermined (qualifier value)
..... caveatList.contrastMediaAllergyKontrastmittelallergieSNOMED CT 373068000: Undetermined (qualifier value)
..... caveatList.drugPrescriptionRelevante Medikamente
...... caveatList.drugPrescription.metforminMetforminSNOMED CT 373068000: Undetermined (qualifier value)
...... caveatList.drugPrescription.betaBlockerBetablockerSNOMED CT 373068000: Undetermined (qualifier value)
... previousResultsVorherige Untersuchungsresultate
.... attachedFileDateiapplication/pdf: VGVzdCBCZWZ1bmQgTm9uIERpY29t
..... attachedFile.descriptionBeschreibungBefund Thorax-Rx 2022
.... dicomObjectDICOM Objekt
..... dicomObject.sopInstanceUidDICOM SOP Instance UID2.16.124.113543.1154777499.30246.19789.3503430088.1.1
..... dicomObject.sopClassDICOM SOP Class[not stated] 1.2.840.10008.5.1.4.1.1.2: 1.2.840.10008.5.1.4.1.1.2
..... dicomObject.modalityDICOM Series Modality[not stated] CT: CT
..... dicomObject.SeriesInstanceUidDICOM Series Instance UID2.16.124.113543.1154777499.30246.19789.3503430088.1
..... dicomObject.studyInstanceUidDICOM Study Instance UID2.16.124.113543.1154777499.30246.19789.3503430088
..... dicomObject.acsnACSN2819497684894126
... noteBemerkungen
.... note.textKommentarVielen Dank für die Beurteilung

doco Documentation for this format